Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Clin Neurol Neurosurg. 2020 Aug;195:105847. doi: 10.1016/j.clineuro.2020.105847. Epub 2020 Apr 15.
The treatment methodology as well as efficacy of stereotactic radiosurgery on numerous brain metastases has not been clearly established despite it being a primary modality for brain metastasis treatment. This study aimed to evaluate the efficacy of two-staged gamma knife radiosurgery (GKS) for patients with more than 10 metastatic lesions.
Staged GKS was applied to 52 patients diagnosed with numerous metastases when a single radiosurgery was unbearable, or the exposed brain volume was excessive. Large clinically significant lesions in the eloquent area were treated in first GKS. The remainders were radiated in second GKS within a 4-week interval. The study evaluated three primary outcomes: 1) the radiological response at second GKS and 3-month follow up, 2) treatment-related side effects, and 3) survival after staged GKS treatment.
Irradiated lesions of 17 (32.7 %) patients showed radiological response on MRI at second GKS. Lesions non-treated at first GKS progressed in 13 (25.0 %) patients during the same period. At the 3-month follow-up, 5 (9.6 %) and 7 (13.5 %) patients were partially responsive and stable, respectively. Given that some patients expired from mostly non-neurological causes before the third follow-up, we could not detect an un-biased radiological progression. Nine (17.3 %) among 52 patients suffered grade 1-3 toxicity until the second GKS, whereas 4 (15.4 %) among 26 survivors suffered grade 1-2 CNS toxicity, but the relationship between irradiation and toxicity remained unclear. Survival rates for 52 patients at 3, 6, 12, 18 and 24 months were 63.9 %, 44.1 %, 23.3 %, 17.8 %, and 13.3 %, respectively. Longer survival after staged GKS treatment was observed in patients with KPS ≥ 80 rather than <70, RPA II rather than III, and PIV < 7000 mm. However, the number of target lesions more or less than 10 was not correlated with survival.
Although the clinical benefit as well as survival gain could not be clearly presented in this study, two-staged GKS for numerous metastases seems to benefit the patients' convenience and risk avoidance. Selected patients, especially with no other treatment options, can be candidates for this treatment protocol.
尽管立体定向放射外科是治疗脑转移的主要方法之一，但对于许多脑转移瘤的治疗方法和疗效仍未明确。本研究旨在评估两阶段伽玛刀放射外科（GKS）治疗 10 个以上转移性病变患者的疗效。
对于无法耐受单次放射外科治疗或暴露脑体积过大的大量转移患者，采用分阶段 GKS。在第一阶段 GKS 中治疗大的、有临床意义的、位于语言区的病灶。4 周内进行第二次 GKS 以照射其余病灶。本研究评估了三个主要结果：1）第二次 GKS 和 3 个月随访时的影像学反应；2）治疗相关的副作用；3）分阶段 GKS 治疗后的生存情况。
17 例（32.7%）患者的照射病灶在第二次 GKS 时 MRI 显示有影像学反应。在同一时期，首次 GKS 未治疗的病灶在 13 例（25.0%）患者中进展。在 3 个月随访时，5 例（9.6%）和 7 例（13.5%）患者部分缓解和稳定。由于一些患者在第三次随访前因非神经原因死亡，我们无法检测到无偏倚的影像学进展。在第二次 GKS 时，52 例患者中有 9 例（17.3%）出现 1-3 级毒性，而 26 例幸存者中有 4 例（15.4%）出现 1-2 级中枢神经系统毒性，但放射与毒性之间的关系仍不清楚。52 例患者的 3、6、12、18 和 24 个月生存率分别为 63.9%、44.1%、23.3%、17.8%和 13.3%。分阶段 GKS 治疗后生存时间较长的患者 KPS≥80 而不是<70，RPA II 而不是 III，PIV<7000mm。然而，病灶数量或多或少与生存无关。
尽管本研究不能明确显示临床获益和生存获益，但两阶段 GKS 治疗大量转移似乎使患者更方便且避免风险。对于没有其他治疗选择的患者，特别是选定的患者，可以考虑这种治疗方案。
